Athletic heart syndrome

Case contributed by David Cuevas


Syncope on exertion. Transthoracic echocardiogram reported enlarged right cardiac chambers. No personal or family history of cardiovascular disease. Intense workout, 2 hours per day, at least 5 days a week during the past 2 years. Heart rate: 45 bpm.

Patient Data

Age: 15 years
Gender: Male

Normal left ventricular wall motion and function, the end-diastolic volume is within the upper normal limits.

Right ventricle depicts mild dysfunction (45.3%), but the end-diastolic and stroke volume is within the upper normal volume.

In the late gadolinium enhancement (LGE) images, a patchy inferoseptal enhancement is shown in the mid ventricle. This finding is common in right ventricle overload and also in athletic heart syndrome.

Left ventricular measurements:

  • end diastolic diameter: 54 mm (normal, 36-56 mm)
  • ejection fraction: 54.6 % (normal: male = 56-78%; female = 56-78%)
  • stroke volume: 95.6 ml
  • end diastolic volume: 175 mL (normal: male = 77-195 mL; female = 52-141 mL)
  • indexed end diastolic volume: 94 mL/m2 (65-95 mL/m2 male)
  • end systolic volume: 79.4 mL (normal: male = 19-72 mL; female = 13-51 mL)
  • cardiac output: 4.3 L/min (normal: male = 2.82-8.82 L/min; female = 2.7-6.0 l/min)

Right ventricular measurements:

  • end diastolic diameter:  50 mm (normal: male 25-46 mm; female 21-39)
  • ejection fraction: 45.3 % (normal: male = 47-74%; female = 47-80%)
  • stroke volume: 93 mL (normal: male = 52-138 mL; female = 35-98 mL)
  • end diastolic volume: 205 mL (normal: male = 88-227 mL; female = 58-154 mL)
  • indexed end diastolic volume: 110.2 mL/m2 (81-111 ml/m2)
  • end systolic volume: 112 mL (normal: male = 23-105 mL; female = 12-68 mL)
  • cardiac output: 4.18 L/min (normal: male = 2.8-8.82 L/min; female = 2.7-6.0 L/min)

Index values are normalized to body surface area (BSA) of 1.86 m2

Case Discussion

Low heart rate, proportional enlargement of cardiac chambers, mild decrease in ejection fraction with preserved stroke volume are findings commonly seen in athletic heart syndrome. In some cases, a patchy LGE is seen in the inferoseptal and anteroseptal segments.

The athlete's heart syndrome refers to both heart enlargement and slow heart rate particularly seen in people exposed to high-performance and sustained exercise or sport (endurance sports, straight exercise, etc) that demands regular physical training program during any time of life.

It is induced by the changes the cardiovascular system has to make in order to be able to deliver the physical performance that is required. The heart tends to increase the size and strength of the ventricles (by hypertrophy and dilatation of the chambers) leading to a morphological big heart with conservated diastolic and systolic function;  heart ejection fraction is sometimes mildly decreased.

The diagnosis is usually made by echocardiography which is the first-line method in order to differentiate from other heart diseases. But the gold standard is cardiac MR, which is superior to echocardiography with 80% sensitivity and 90% specificity of cine CMR 1.

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